The positive impact of a telemedicine education program on healthcare workers during the COVID-19 pandemic in Ontario, Canada.

Context The impact of the COVID-19 pandemic on health care service and delivery has been profound. In addition to shifting and expanding clinical responsibilities, rapidly evolving information and guidelines during the COVID-19 pandemic has made it difficult for healthcare workers (HCWs) to synthesize and translate COVID-19 information into practice. Objective The objectives of this study are 1) to examine the impact of a telemedicine education program on HCW's self-efficacy and satisfaction and 2) to explore HCWs' experience in the program and context of practice during the COVID-19 pandemic. Study Design We conducted a prospective mixed methods parallel-design study among ECHO COVID participants using pre-post questionnaires and focus group discussions (FGDs). We examined questionnaire results for changes in HCWs' self-efficacy and satisfaction. We analyzed FGD data to explore HCWs' experience in ECHO and the context of their practice during the COVID-19 pandemic. Setting Project Extension for Community Healthcare Outcomes (ECHO) model is a virtual, telemedicine education model that provides longitudinal support and addresses the emerging needs of HCWs. "ECHO Ontario: Managing COVID-19 Patients in the Community" (ECHO) was launched in July 2020. The goal of the program was to disseminate best practices regarding COVID-19 as they emerged and to increase HCW confidence and knowledge of COVID-19. Population Studied The study population were practicing HCWs in the province of Ontario, Canada. 1) HCW self-efficacy 2) HCW satisfaction Results Of 299 HCWs registered in ECHO COVID, 114 (38.1%) participated in this analysis. Median self-efficacy scores increased from 5 (IQR 4 - 6) to 6 (IQR 6 - 6) (p < 0.0001), independent of profession, years in practice, age group, or type of practice environment. Participants were highly satisfied with the ECHO sessions with a median score of 4 (IQR 4 - 5). FGD data indicated that HCWs gained knowledge through ECHO, established the context of their practice, and revealed facilitators for ECHO program success, including the transition to virtual care, the practicability of knowledge provided, and a "perspective from the trenches." Conclusions This study demonstrated that a telemedicine education program aimed to support HCWs in managing patients with COVID-19 had a positive impact on self-efficacy and satisfaction, and that this impact was specifically mediated through the ECHO program.

Positive impact of a telemedicine education program on practicing health care workers during the COVID-19 pandemic in Ontario, Canada: A mixed methods study of an Extension for Community Healthcare Outcomes (ECHO) program.

INTRODUCTION: In addition to shifting and expanding clinical responsibilities, rapidly evolving information and guidelines during the COVID-19 pandemic has made it difficult for health care workers (HCW) to synthesise and translate COVID-19 information into practice. This study evaluated whether a COVID-19-specific telemedicine education program (ECHO COVID) would impact health care workers' self-efficacy and satisfaction in the management of patients with COVID-19. METHODS: A prospective mixed methods parallel-design study was conducted among ECHO COVID participants using pre-post questionnaires and a focus group discussion. Questionnaire results were examined for changes in health care workers' self-efficacy and satisfaction. Focus group discussion data were analysed to explore health care workers' experience in ECHO COVID and the context of their practice during the COVID-19 pandemic. RESULTS: 239 health care workers registered in ECHO COVID and 114 (47.7%) completed questionnaires and attended at least one ECHO COVID session. Median self-efficacy scores increased from 5 (IQR 4-6) to 6 (IQR 6-6) (p < 0.0001), independent of profession, years in practice, age group, or practice environment. Participants were highly satisfied with ECHO COVID sessions with a median score of 4 (IQR 4-5). Focus group discussion data indicated that health care workers gained knowledge through ECHO COVID and revealed facilitators for ECHO COVID program success, including the transition to virtual care, the practicability of knowledge provided, and a 'perspective from the trenches.' DISCUSSION: This study demonstrated that a telemedicine education program aimed to support health care workers in managing patients with COVID-19 had a positive impact on health care workers' self-efficacy and satisfaction. This impact was specifically mediated by the ECHO COVID program.

A Qualitative Investigation Into Faith and LGBTQ Identities in a Nonclinical Sample of Readers of the Dear Abby Column: The Dear Abby Project.

ABSTRACT: To better understand the relationship between faith and LGBTQ+ identity, we conducted a qualitative analysis of 86 respondents to a general question posed through the Dear Abby column. Responses were anonymized and analyzed using a grounded theory approach. Analysis revealed six themes, reflecting a diversity of lived experience from community rejection to acceptance, and self-rejection to feelings of acceptance by God. Despite frequent media portrayals of conflict between faith and LGBTQ+ identity, the reality is more complex, and faith and LGBTQ+ identity development can be complementary.

Feasibility and Limitations of Proning Protocol for Nonintubated Patients With COVID-19.

Proning awake patients with COVID-19 is associated with lower mortality and intubation rates. However, these studies also demonstrate low participation rates and tolerance of awake proning. In this study, we attempt to understand barriers to proning. Medical and dental students surveyed nonintubated patients to understand factors affecting adherence to a proning protocol. Only patients who discussed proning with their medical team attempted the practice. Eight of nine patients who were informed about benefits of proning attempted the maneuver. Discomfort was the primary reason patients stopped proning. Addressing discomfort and implementing systematic patient education may increase adherence to proning.

Intensive and app-delivered occupational therapy to improve upper extremity function in early diffuse cutaneous systemic sclerosis: a pilot two-arm trial.

OBJECTIVE: SSc reduces upper extremity function and performance of everyday activities; however, there are few evidence-based rehabilitation interventions. This study examined short and longer-term effects of two occupational therapy interventions on hand disability. METHODS: Participants with diffuse cutaneous SSc were randomized to one of two 18-week interventions: Intensive group, receiving eight weekly in-person occupational therapy sessions with App-delivered home exercises, or App Alone group. The primary outcome was QuickDASH hand disability; secondary outcomes were physical function (PROMIS scale), and total active hand motion. Linear mixed models were used to examine treatment effects. RESULTS: Most participants were female (72%); the mean age was 52 years (13.4) (n = 32). There were no significant between-group effects on QuickDASH (P = 1.0; mean change -6.4 on 0-100 scale in both groups at 18 weeks). Left lateral pinch, an exploratory outcome, improved in App Alone compared with Intensive from baseline to 18 weeks. Within groups, the Intensive group had the largest improvements after 8 weeks (-8.5 on QuickDASH; P = 0.03), but then lost gains from 8 to 18 weeks while the App Alone group had modest improvements from baseline to 8 weeks, but then continued to improve. Of completers, 50% had clinically meaningful improvement on QuickDASH in the Intensive group and 64% had improvement in App Alone. CONCLUSION: Both interventions showed beneficial effects on hand disability. Participants in the App Alone group improved equally to the Intensive group at 18 weeks. Our findings provide support for further study into telehealth rehabilitation approaches. TRIAL REGISTRATION: NCT03482219.

Collagen IVα345 dysfunction in glomerular basement membrane diseases. III. A functional framework for α345 hexamer assembly.

We identified a genetic variant, an 8-residue appendage, of the α345 hexamer of collagen IV present in patients with glomerular basement membrane diseases, Goodpasture's disease and Alport syndrome, and determined the long-awaited crystal structure of the hexamer. We sought to elucidate how variants cause glomerular basement membrane disease by exploring the mechanism of the hexamer assembly. Chloride ions induced in vitro hexamer assembly in a composition-specific manner in the presence of equimolar concentrations of α3, α4, and α5 NC1 monomers. Chloride ions, together with sulfilimine crosslinks, stabilized the assembled hexamer. Furthermore, the chloride ion-dependent assembly revealed the conformational plasticity of the loop-crevice-loop bioactive sites, a critical property underlying bioactivity and pathogenesis. We explored the native mechanism by expressing recombinant α345 miniprotomers in the cell culture and characterizing the expressed proteins. Our findings revealed NC1-directed trimerization, forming protomers inside the cell; hexamerization, forming scaffolds outside the cell; and a Cl gradient-signaled hexamerization. This assembly detail, along with a crystal structure, provides a framework for understanding hexamer dysfunction. Restoration of the native conformation of bioactive sites and α345 hexamer replacement are prospective approaches to therapeutic intervention.

Development of a Musculoskeletal Ultrasound Protocol to Examine Upper Extremity Rehabilitation Outcomes in Systemic Sclerosis.

OBJECTIVES: This study developed a musculoskeletal ultrasound (MSUS) protocol to evaluate rehabilitation outcomes in systemic sclerosis. MATERIALS & METHODS: Three MSUS methods (grey scale, Doppler, strain elastography) and two acquisition techniques (long versus short axis; transducer on skin versus floating on gel) were examined in the forearm before and after rehabilitation treatment. For grey-scale, tissue thickness measures, intra- and inter-rater reliability were calculated (ICCs), and paired t-tests examined differences among techniques. RESULTS: Five people with diffuse cutaneous systemic sclerosis participated. The most valid and reliable grey-scale technique was with the transducer in long-axis, floating on gel. Doppler and strain elastography did not detect changes. Both dermal and subcutaneous thickness measurement error was small; intra- and inter-rater reliability was good to excellent. Preliminary data indicate that treatment may lead to dermal thinning. CONCLUSION: A replicable protocol was established and may be an adjunct to rehabilitation outcome measurement in systemic sclerosis.

Assessment of metal contamination in Arabian/Persian Gulf fish: A review.

Metal contamination in fish is a concern worldwide, including in the Arabian/Persian Gulf region. This review summarizes the findings from 55 papers about metal concentrations in Gulf fish. Metal concentrations in muscle tissue were screened against the most recent maximum allowable levels (MALs) for fish in international commerce. We identified metals, fish species, and locations where concentrations exceeded the MALs. For some metals, recent MALs have been set to lower concentrations as more toxicological data have become available. Mean fish tissue concentrations exceeded the MAL in 13% (arsenic), 76% (cadmium), 56% (lead), and 10% (mercury) of species means. We identified 13 fish species with the potential to serve as bioindicators of metal contamination for use in four Gulf habitats: pelagic, benthopelagic, demersal, and coral reefs. Recommendations are provided for a regional approach to improve consistency of sampling, data analysis and reporting of metal concentrations in Gulf fish.

Cardiac arrhythmia considerations of hormone cancer therapies.

Breast and prostate cancers are among the most prevalent cancers worldwide. Oestradiol and progesterone are major drivers for breast cancer proliferation, and androgens for prostate cancer. Endocrine therapies are drugs that interfere with hormone-activated pathways to slow cancer progression. Multiple new breakthrough drugs improving overall survival have recently been developed within this class. As the use of these latter drugs grows, incidence of cardiac arrhythmias has emerged as an unappreciated complication. These changes are not surprising given that sex hormones alter ventricular repolarization. Testosterone shortens action potential duration and QT interval duration, while oestradiol has an opposite effect. In patients with breast cancer, selective oestrogen receptor modulators are associated with more reports for long QT and torsade de pointes (TdP) than aromatase inhibitors, likely through an oestradiol-like effect on the heart. Cyclin-dependent kinase 4/6 inhibitors, a new class of anticancer drugs used in combination with endocrine therapies in hormone receptor positive breast cancer, are also variably associated with drug-induced long QT, particularly with ribociclib. In prostate cancer, androgen deprivation therapy is associated with long QT and TdP, and possibly atrial fibrillation for abiraterone. In this review, we have summarized the clinical and preclinical data focusing on cardiac arrhythmia considerations of hormone cancer therapies.

Occupational Therapy Treatment to Improve Upper Extremity Function in Individuals with Early Systemic Sclerosis: A Pilot Study.

OBJECTIVE: To determine the feasibility and preliminary effects of occupational therapy to improve upper extremity function in patients with early systemic sclerosis (SSc; scleroderma) who have upper extremity contractures. METHODS: A single-group pilot clinical rehabilitation trial was conducted at the University of Michigan Scleroderma Center. Patients with SSc and ≥1 upper extremity contracture (n = 21) participated in a total of 8 weekly in-person occupational therapy sessions. The therapy consisted of thermal modalities, tissue mobilization, and upper extremity mobility exercises. The participants were instructed to perform upper extremity exercises at home between sessions. Feasibility was measured by the percent enrollment as well as session attendance and session duration. The primary outcome measure was the Shortened Disabilities of the Arm, Shoulder and Hand measure (QuickDASH); secondary and exploratory outcomes included the Patient-Reported Outcomes Measurement Information System (PROMIS) physical function measures; objective measures of upper extremity mobility, strength, and coordination; and skin thickening. Linear mixed models were used to determine the effects of treatment on the primary and secondary outcomes. RESULTS: Fifty percent of potentially eligible subjects (24 of 48) were interested in participating. Twenty-one (88%) of the 24 subjects were enrolled, and 19 (91%) of these 21 subjects completed all sessions. The mean ± SD age of the participants was 47.9 ± 16.1 years; 100% had diffuse SSc, and the mean disease duration was 3.1 years. At 8 weeks, participants had statistically significant improvement in the QuickDASH and PROMIS physical function measure (P = 0.0012 and P = 0.004, respectively). Approximately one-half of participants in the sample achieved improvement in the QuickDASH and PROMIS measure that exceeded minimally important differences. CONCLUSION: In-person treatment sessions were feasible in the patients with SSc and resulted in statistically significant and clinically meaningful improvements in upper extremity and physical function. In future studies, the effects of SSc should be compared with those in a control condition, and the durability of treatment effects should be examined.

Cardiovascular care of patients with chronic myeloid leukemia (CML) on tyrosine kinase inhibitor (TKI) therapy.

Cardiovascular (CV) health has emerged as an important consideration in patients with chronic myeloid leukemia (CML) because of improved prognosis. Indeed, the success of BCR-ABL1 tyrosine kinase inhibitors (TKIs) has increased the focus on survivorship and late toxicity in oncological care. Survivorship issues in this population include CV disease prevention, given its prevalence in the general population. The introduction of BCR-ABL1 TKIs represented a unique concept of indefinite cancer therapy, only recently evolving to include "treatment-free remission." Importantly, later-generation BCR-ABL1 TKIs have been associated with CV complications. Dasatinib has been associated with pleural/pericardial effusions and pulmonary hypertension, whereas nilotinib and ponatinib have been linked to the development of vascular occlusive events. There is currently a dearth of data with respect to the mechanisms of drug toxicities, the subsets of patients at risk, and prevention and treatment strategies to mitigate CV complications in patients with CML. Nevertheless, optimal patient CV risk assessment needs to become a more central tenet of patient care in CML. We propose several practical considerations for the practicing oncologist relative to the CV health of patients with CML, especially those on chronic TKI therapy.

Loss of the melanocortin-4 receptor in mice causes dilated cardiomyopathy.

Haploinsufficiency of the melanocortin-4 receptor, the most common monogenetic obesity syndrome in humans, is associated with a reduction in autonomic tone, bradycardia, and incidence of obesity-associated hypertension. Thus, it has been assumed that melanocortin obesity syndrome may be protective with respect to obesity-associated cardiovascular disease. We show here that absence of the melanocortin-4 receptor (MC4R) in mice causes dilated cardiomyopathy, characterized by reduced contractility and increased left ventricular diameter. This cardiomyopathy is independent of obesity as weight matched diet induced obese mice do not display systolic dysfunction. Mc4r cardiomyopathy is characterized by ultrastructural changes in mitochondrial morphology and cardiomyocyte disorganization. Remarkably, testing of myocardial tissue from Mc4r-/- mice exhibited increased ADP stimulated respiratory capacity. However, this increase in respiration correlates with increased reactive oxygen species production - a canonical mediator of tissue damage. Together this study identifies MC4R deletion as a novel and potentially clinically important cause of heart failure.

Pathogen reduction co-benefits of nutrient best management practices.

BACKGROUND: Many of the practices currently underway to reduce nitrogen, phosphorus, and sediment loads entering the Chesapeake Bay have also been observed to support reduction of disease-causing pathogen loadings. We quantify how implementation of these practices, proposed to meet the nutrient and sediment caps prescribed by the Total Maximum Daily Load (TMDL), could reduce pathogen loadings and provide public health co-benefits within the Chesapeake Bay system. METHODS: We used published data on the pathogen reduction potential of management practices and baseline fecal coliform loadings estimated as part of prior modeling to estimate the reduction in pathogen loadings to the mainstem Potomac River and Chesapeake Bay attributable to practices implemented as part of the TMDL. We then compare the estimates with the baseline loadings of fecal coliform loadings to estimate the total pathogen reduction potential of the TMDL. RESULTS: We estimate that the TMDL practices have the potential to decrease disease-causing pathogen loads from all point and non-point sources to the mainstem Potomac River and the entire Chesapeake Bay watershed by 19% and 27%, respectively. These numbers are likely to be underestimates due to data limitations that forced us to omit some practices from analysis. DISCUSSION: Based on known impairments and disease incidence rates, we conclude that efforts to reduce nutrients may create substantial health co-benefits by improving the safety of water-contact recreation and seafood consumption.

The Growing Regulation of Conversion Therapy.

Conversion therapies are any treatments, including individual talk therapy, behavioral (e.g. aversive stimuli), group therapy or milieu (e.g. "retreats or inpatient treatments" relying on all of the above methods) treatments, which attempt to change an individual's sexual orientation from homosexual to heterosexual. However these practices have been repudiated by major mental health organizations because of increasing evidence that they are ineffective and may cause harm to patients and their families who fail to change. At present, California, New Jersey, Oregon, Illinois, Washington, DC, and the Canadian Province of Ontario have passed legislation banning conversion therapy for minors and an increasing number of US States are considering similar bans. In April 2015, the Obama administration also called for a ban on conversion therapies for minors. The growing trend toward banning conversion therapies creates challenges for licensing boards and ethics committees, most of which are unfamiliar with the issues raised by complaints against conversion therapists. This paper reviews the history of conversion therapy practices as well as clinical, ethical and research issues they raise. With this information, state licensing boards, ethics committees and other regulatory bodies will be better able to adjudicate complaints from members of the public who have been exposed to conversion therapies.

Towards Advancing Knowledge Translation of AAC Outcomes Research for Children and Youth with Complex Communication Needs.

The production of new knowledge in augmentative and alternative communication (AAC) requires effective processes to leverage the different perspectives of researchers and knowledge users and improve prospects for utilization in clinical settings. This article describes the motivation, planning, process, and outcomes for a novel knowledge translation workshop designed to influence future directions for AAC outcomes research for children with complex communication needs. Invited knowledge users from 20 pediatric AAC clinics and researchers engaged in the collaborative development of research questions using a framework designed for the AAC field. The event yielded recommendations for research and development priorities that extend from the early development of language, communication, and literacy skills in very young children, to novel but unproven strategies that may advance outcomes in transitioning to adulthood.

Motherhood in women with serious mental illness.

This study aimed to determine the prevalence of motherhood among inpatient females at a large state psychiatric hospital in suburban New York, as well as develop an understanding of the characteristics and needs of this unique population. Data on motherhood status was gathered from October 2010 through April 2011 via medical records. Data on custody status, frequency of contacts with children, and effect of mental illness on parenting was assessed through patient surveys and focus groups. 38.5 % of female inpatients were found to be mothers, almost half of whom reported at least weekly contact with children despite their inpatient status. The majority of identified mothers reported having maintained custody of their minor children and expressed great pride at being primary caretakers for their children, yet also emphasized the challenging effects of stigma associated with mental illness and parenting. A significant proportion of women at this psychiatric hospital were found to be mothers. Although acknowledged by some clinicians at the individual level, motherhood appears to remain a forgotten role systemically. Determining motherhood status and recognizing the varied roles our patients have is one more way mental health providers can model and promote recovery-oriented care.

Site-specific inheritance of basal cell carcinoma.

We report a 21-year-old white woman who developed a large basal cell carcinoma (BCC) on her left upper vermilion border. Her mother and maternal grandmother both had a history of BCCs occurring in the same location. No documented BCC-related genetic disorder was suspected. Our case supports a theory of site-specific inheritance of nonmelanoma skin cancer, which should be further explored.

Recovery as the new medical model for psychiatry.

Treatment grounded in recovery principles is often viewed as not being based on the "medical model." In this Open Forum the author asserts that recovery from mental illness is entirely compatible with concepts of recovery from medical illness and with new approaches to medical treatment. Three ways of conceptualizing recovery are defined: clinical recovery, illness management, and personal recovery. Basing treatment on recovery principles is supported by research that has shown significant remission rates over time among persons with schizophrenia. The author uses examples of public figures and of one family with physical disabilities to illustrate the progress society has made toward accepting and including people with physical illness and disability. Recovery-oriented mental health treatment parallels the move in other medical specialties toward person-centered care. A clinical approach to promote recovery is discussed.

A day in the life of a public psychiatry fellow.

Now in its 29th year, the Public Psychiatry Fellowship of the New York Psychiatric Institute at Columbia Medical Center selects 10 fellows per year for its 1-year program (1). This award-winning fellowship trains future leaders for the public mental health sector. The curriculum (2) employs a combination of a didactic seminar series, management-problem-focused presentations by guest speakers, field trips, and supervision by fellowship faculty to instill the values and skills required for practice and leadership in the public sector. Fellows utilize the framework of the academic curriculum to carry out a series of presentations throughout the year that allow them to organize, implement and evaluate concepts that they learn during the year. The following account, written from bird's eye view, details one fellow's day at his field placement in a State Hospital outpatient clinic setting, with the aim of illustrating how the concepts taught by the fellowship find application in day to day practice.